Basic Information
| Provider Information | |||||||||
| NPI: | 1437250859 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KAISERMAN | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | BRADLEY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 W MERCED AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | WEST COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917903401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268139988 | ||||||||
| FaxNumber: | 6268130075 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 W MERCED AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | WEST COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917903401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268139988 | ||||||||
| FaxNumber: | 6268130075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0205X | G78831 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology |
ID Information
| ID | Type | State | Issuer | Description | 00G788310 | 05 | CA | MEDICAID |